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..SC 0.0.C5'�- 2'LJ1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emerge n Res nse Pho 4.Manifest Tracking Number <br /> WASTE MANIFEST CA000022022 oo- JJ K <br /> I.6* C ailing Address Generators Site Address(d different than mailing address) <br /> 7701 TAM O'SKANTER L.N. <br /> STOCKTON,CA 95210 <br /> Generator's Phone: 209-952-7812 <br /> 6.TransporF4U.S.EPA ID Number <br /> 9Ynvironmental Services CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Faality Name and Site Addres vergreen I , Inc. U S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 CAD980887418 <br /> Facllitys Phone: 510-795-4400 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group('if any)) No. Type Quantity WtNol. 13.Waste Codes <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14 ling Instructions and Additional Information /7 / <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc bed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) r(b)(if I am a small quantity gene ' r)is true. <br /> MMontGG ratoes/Offeror's Printed/Typed Name Signa <br /> h Day Year <br /> C� c,o r �'aZ 419 <br /> 16.Intemational Shipments <br /> ❑Import to U.S. Expon from U.S. Port of entry/exit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Ackn gment of Receipt of Materials <br /> Transporter 1 Pn ed Na � Signatu Month Day Yea <br /> O d <br /> CL <br /> ZTrans r 2 Pnnted/Typed Name ignature Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua. Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1. 2. 3.. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1Ba - <br /> ted/Typed Name Signature Month Day Year <br /> Pnn <br /> —. <br /> I Is 1117 1013 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNAT FACIL O DESTINATION STATE(IF REQUIRED) <br /> 10301.0397 <br />